Short Report: Stranded in the web of evidence and ethics

Natural Orifice Translumenal Endoscopic Surgery (NOTES) is the execution of a diagnostic or therapeutic intervention within the peritoneal cavity with flexible endoscope, which is passed through a natural orifice. NOTES earned its nomenclature and worldwide recognition following trans gastric liver biopsy in a porcine model by Kalloo et al. in 2004. It is generally regarded as 3rd generation surgery, which has the potential to replace current modes of surgical treatment. The technical feasibility of NOTES is proven in animals after scores of procedures through trans gastric, trans vaginal, trans colonic and trans vesical routes: cholecystectomy, appendectomy, splenectomy bowel resection-anastamosis, gastrojejunostomy and tubal ligation. These surgical landmarks have prompted NOTES enthusiasts to conduct several operations in humans: appendectomy, peritoneoscopy and cholecystectomy. There is no consensus on the best route of access to the abdominal cavity. The trans gastric approach seems to be very popular in spite of difficulty in recognition of retroflexed organs in the upper abdomen. Currently, NOTES depends on technology borrowed from flexible endoscopy.